Double percutaneous transesophageal gastrotubing precluded high risk surgery for intestinal malignant lymphoma

Hideyuki Takeuchi; Teppei Kamada; Hironori Ohdaira; Junji Takahashi; Keigo Nakashima; Yuichi Nakaseko; Masashi Yoshida; Shinya Okada; Eigoro Yamanouchi; Yutaka Suzuki

doi:10.1016/j.amsu.2021.102198

Double percutaneous transesophageal gastrotubing precluded high risk surgery for intestinal malignant lymphoma

Ann Med Surg (Lond). 2021 Feb 27:64:102198. doi: 10.1016/j.amsu.2021.102198. eCollection 2021 Apr.

Affiliations

¹ Department of Surgery, International University of Health and Welfare Hospital, Japan.
² Department of Pathology, International University of Health and Welfare Hospital, Japan.
³ Department of Radiology, International University of Health and Welfare Hospital, Japan.

Abstract

Primary gastrointestinal lymphoma is relatively rare and typically treated by chemotherapy. In some cases, surgery for obstruction in the proximal small intestine is challenging and has a high risk for anastomotic leakage. An 80-year-old woman presented to our hospital with vomiting and abdominal distension. Enteroscopy showed a type 2 circumferential tumor in the proximal jejunum 6 cm on the anal side from Treitz ligament. Biopsy showed solid and diffuse proliferation of large atypical cells with round and irregular nuclei. On immunohistochemistry, these cells were positive for CD20, CD79a, and CD138. Diffuse large B-cell lymphoma (DLBCL) was diagnosed and classified as Ann Arbor stage IIE and Lugano classification stage II 2 and scored 1 point on the International Prognostic Index (i.e., low risk). Given the risk of anastomotic leakage due to lesions and residual obstructive enteritis, surgery was not performed. The patient received double percutaneous transesophageal gastrotubing (dPTEG) to facilitate decompression and enteral nutrition. Enteral nutrition and chemotherapy were initiated immediately after dPTEG insertion. After one course of rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (R-CHOP), the tumor showed a partial response, and the obstruction was improved. Oral ingestion was started, and the dPTEG tube was removed. After six courses of R-CHOP, enhanced CT, positron emission tomography-CT, and serum interleukin-2 levels indicated complete treatment response. During treatment, gastrointestinal perforation did not occur, oral intake was good, and careful follow-up will be continued. dPTEG for obstructive small intestinal DLBCL could help avoid high-risk surgery, and a complete response to chemotherapy was achieved.

Keywords: Bowel obstruction; CHOP, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone; DLBCL, diffuse large B-cell lymphoma; Diffuse large B-Cell lymphoma; Malignant lymphoma; PEG, percutaneous endoscopic gastrostomy; PGINHL, primary gastrointestinal non-Hodgkin's lymphoma; PTEG, percutaneous trans-esophageal gastro-tubing; Percutaneous transesophageal gastrotubing; R–CHOP, rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone; Small intestine; dPTEG, double percutaneous transesophageal gastrotubing.

Publication types

Case Reports